Complications of Sinusitis Dr. Krishna Koirala 2018-08-13 Definition • Progress of infection beyond the muco-periosteal lining of paranasal sinuses to involve the bone and neighboring structures (orbit, intra-cranial cavity, dentition) • Compromise in function of any part of body due to sinusitis Etiology • Weak immune response of host – Young children and immuno -compromised adults • Inadequate / inefficient treatment • Infection by highly virulent organisms • Abnormalities of muco- cilliary clearance • Persistent allergy and blockade of sinus ostia Routes of infection • Via thin bones eg. lamina papyracea • Through natural suture lines • Through natural canal: infra-orbital canal • Retrograde thrombophlebitis: diploic vein of Breschet • Closely related roots of upper 2nd premolar & 1st molar teeth • Periarteriolar spaces of Virchow Robin Classification • Acute • Chronic – Mucocele – Local •Orbital – Pyocele • Associated diseases (?) •Intracranial – Otitis media •Bony – Adeno -tonsillitis •Dental – Bronchiectasis – Distant •Toxic shock syndrome Orbital Complications ( Chandler et al 1970) 1. Pre-septal cellulitis 2. Orbital cellulitis without abscess 3. Orbital cellulitis with extra/ sub-periosteal abscess 4. Orbital cellulitis with intra-periosteal abscess 5. Cavernous sinus thrombosis Intracranial Complications 1. Meningitis 2. Encephalitis 3. Extra-dural abscess 4. Sub-dural abscess 5. Intra-cerebral abscess 6. Cavernous sinus thrombosis 7. Sagittal sinus thrombosis • Bony – Osteitis – Osteomyelitis (Pott’s puffy tumour) • Dental − Dental abscess − Oro-antral fistula Orbital complications • Commonest complication of sinusitis • Young people at high risk: 85% < 20 yrs age • Ethmoid sinus most commonly implicated Frontal Sphenoid Maxillary • Left orbit more commonly involved (?) Pre-septal cellulitis • Inflammation external to orbital septum • Edema of eyelids: – Upper lid : frontal sinusitis – Lower lid : maxillary sinusitis – Both lids : ethmoid sinusitis • No tenderness , visual loss , limitation of extra-ocular movement Orbital Cellulitis without abscess • Inflammation of adipose tissue deep to peri-orbital septum without suppuration • Diffuse peri -orbital edema with erythema • Mild proptosis • No restriction of extra-ocular movement • No change in vision Extra-periosteal abscess • Most common form of orbital cellulitis • Localized extra-periosteal pus collection • Mild proptosis, restriction of extra-ocular movement , vision loss • Color vision affected first – Red = brown – Blue = black Extra-periosteal abscess Orbital cellulitis with Intra-periosteal abscess • Mild chemosis (edema of conjunctiva) • Proptosis: severe, asymmetric, quadrantic – Frontal sinusitis : down + forward + lateral – Ethmoid sinusitis : forward + lateral – Maxillary sinusitis : up + forward • Concurrent and complete ophthalmoplegia • Visual loss due to optic neuropathy (up to 13% of cases) Intra-periosteal abscess Cavernous Sinus Thrombosis • Rapid onset, hectic fever • Bilateral orbital pain + severe chemosis • Bilateral absent pupillary reflex • Bilateral symmetrical axial proptosis • Sequential ophthalmoplegia (VI III IV) • Papilledema + loss of vision • Painful paresthesia of V1, V2 Cavernous Sinus Thrombosis B/L chemosis + proptosis Cavernous sinus Thrombosis Orbital abscess Bilateral Unilateral Rapidly progressive Slowly progressive Hectic fever Low grade fever Severe chemosis Mild chemosis Paraesthesia of V1, V2 No paraesthesia Sequential ophthalmoplegia Concurrent pan-ophthalmoplegia Asymmetric quadrantic proptosis Symmetric axial proptosis Evaluation of orbital complication • Ophthalmology consultation – Look for edema of eyelids, displacement of eyeball (proptosis), restriction of ocular movement – Visual acuity and color vision examination – Fundoscopy for papilledema • CT scan PNS (including orbit): coronal and axial cuts Medical Treatment • Broad spectrum, high dose IV antibiotics – Ceftriaxone + Metronidazole+ Amikacin • NSAIDs • Topical / oral nasal decongestants • Mucolytics: Bromhexine, Ambroxol, Guaphanesin • Nasal saline irrigation Surgical Treatment • For sinusitis – Frontal sinus trephination – External fronto-ethmoidectomy (Lynch Howarth) – Functional Endoscopic Sinus Surgery ( FESS) • For orbital complications – Sub-periosteal abscess drainage – Orbital decompression Intra-cranial complications Introduction • 2nd most common complication of sinusitis • Most common in adolescents & young adults (diploic venous system at peak vascularity) • Frontal sinus most commonly implicated Ethmoid Sphenoid Maxillary • Commonest route of spread : Retrograde thrombophlebitis via Diploic vein of Breschet Intra-cranial complications Clinical Features • Fever • Deep-seated headache • Nausea & projectile vomiting • Neck stiffness • Seizures • Altered sensorium & mood changes • Late: bradycardia / hypotension / stupor Frontal lobe abscess Investigations and Medical Treatment • Neurosurgery consultation • CT scan PNS + brain with contrast • MRI with contrast: investigation of choice • High dose broad spectrum I.V. antibiotics: Ceftriaxone & Metronidazole for 4-6 week • Steroids : controversial Surgical treatment for abscess • For sinuses: – Frontal trephination – External fronto-ethmoidectomy (Lynch Howarth) – Functional Endoscopic Sinus Surgery • For intra-cranial complication: by Neurosurgeon – Burr hole drainage for small abscess – Craniotomy for large brain abscess Mucocoele of P.N.S. Introduction • Definition: epithelium lined, mucus filled sac filling the paranasal sinus that is capable of expansion • Incidence: – Frontal : 65 % – Ethmoid : 25 % – Maxillary : 10 % – Sphenoid : rare Etiology • Chronic obstruction of sinus ostium with retention of normal sinus mucus within sinus cavity • Mucous retention cyst : Develops from obstruction of ducts of sero mucinous glands within sinus mucosa Clinical Features • Cystic, non-tender swelling above inner canthus with egg-shell crackling sensation on palpation • Proptosis: – Frontal : downward + forward + lateral – Ethmoid : forward + lateral – Maxillary : up + forward • Diplopia & restricted eyeball movement • Frontal headache, retro-orbital or facial pain Fronto-ethmoid mucocele Investigations – X-ray PNS OM view: expanded frontal sinus, loss of scalloped margins, translucency, depression or erosion of supra-orbital ridge – CT scan: homogenous smooth walled expanding the sinus with thinning of bone – Ring enhancement on contrast: pyocoele mass Fronto-ethmoid mucocele Fronto-ethmoid mucocoele with proptosis Sphenoid mucocoele Treatment 1. Antibiotics and nasal decongestants 2. External fronto-ethmoidectomy by Lynch – Howarth’s approach 3. Endoscopic fronto-ethmoidectomy 4. Endoscopic decompression (marsupialization) 5. Osteoplastic flap repair Lt. Ethmoid mucocoele Drainage + Marsupialization Post-op CT scan (coronal) Frontal pyocele + fistula Osteoplastic flap procedure for frontal sinus mucocele Pott’s puffy tumour • Frontal sinus osteomyelitis (Percival Pott, 1760) • Fluctuant swelling over forehead anteriorly • May spread posteriorly leading to subdural abscess • Treatment – Six week course of broad spectrum antibiotics – Drainage of pus & debridement of bone – Obliteration of frontal sinus by osteoplastic flap technique Pott’s puffy tumour Oro-antral fistula • Fistulous tract communicating between oral cavity and maxillary antrum • Treatment : closure by – Buccal mucosal advancement flap – Palatal flap – Buccal fat pad flap Toxic shock syndrome • Rare, potentially fatal complication of sinusitis • Septicemia due to Staphylococcus aureus or Streptococcus infection • C/F: – Fever, hypotension, skin rashes with desquamation, multisystem failure • Treatment – IV Ceftriaxone 1g TDS – FESS and drainage of pus from the sinuses
